Ebook Oxford textbook of spirituality in healthcare: Part 1

(BQ) Part 1 book “Oxford textbook of spirituality in healthcare” has contents: Christianity, feminist spirituality, indian religion and the ayurvedic tradition, the western humanist tradition, indigenous spiritualties, meaning making, cure and healing,… and other contents.

Oxford Textbook of Spirituality in Healthcare

Supportive Care Studies Group, University of Liverpool; Honorary Lecturer, University of Sheffield (UK)

Christina M Puchalski Professor of Medicine and Health Sciences at The George Washington University School of Medicine and Director of the George Washington

Institute for Spirituality and Health, Washington, DC

(USA) and

Bruce Rumbold Director, Palliative Care Unit, School

of Public Health and Human Biosciences, La Trobe University (AUS)

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Edmund D Pellegrino

Experienced clinicians have long known that true healing extends beyond theartful use of medical knowledge They grasped intuitively that serious or fatalillness was an ontological assault, an existential assault on the whole of thepatient's lived world To heal, the physician must recognize the starkness of thepatient's encounter with his own finitude, i.e with his mortality and inherentlimitations Healing of the psychosocial-biological is of itself insufficient torepair the existential disarray of the patient's life without recognition of thespiritual origins of that disarray

In centuries past, little genuinely scientific therapy was available The causesand treatment of disease were often sought in frankly spiritual forces For manycenturies spiritual and ‘scientific’ medicine were practiced side-by-side In theWest, clinicians practiced their art with varying degrees of cooperation betweenHippocratic and religiously oriented views of health and disease Similarconfluences of religious and secular treatments existed in the Eastern world aswell

As the era of scientifically effective medical practice expanded, the humaneand spiritual dimension of illness and healing were more clearly separated Acertain degree of hubris on both sides led many to deprecate the connectionbetween ‘scientific’ and religious or spiritual notions of healing Today, even asscientific medicine expands in therapeutic potency, there is a renewed awareness

of what the experienced clinicians never neglected The modern emphasis on

‘wholistic’ medicine recognized the disarraying effect of illness on the whole life

of the patient Once again whatever term is used to define the phenomenon, thesignificance of illness as a disarray of the patient's life is now becoming moreprecisely recognized

This comprehensive, authoritative, multicultural volume edited by MarkCobb, Christina Puchalski, and Bruce Rumbold provides an indispensable guide

to clinical practice, research and education in the realms of healing beyond thecapabilities of modern scientific medicine alone

The three editors have assembled an impressive representation of clinicians,

investigators, and teachers engaged in the practice and research in the place ofspirituality in medicine Taken together they illustrate the significance, andbreadth of definitions of ‘spirituality’ across a wide spectrum of cultures,medical theories, and historical precedents The significance for patients of allkinds is extensively explored—in acute and chronic illness, palliative, terminal,and geriatric care.

In each contribution the authors have provided a wide range of discussionscrossing cultural, historical, theoretical boundaries The practical dimensions ofdiagnosis, modes of therapy and cooperation at the bedside are well documented.The differences in definitions of spirituality, and clinical usage of relevant termsand modes of therapy are well delineated

The editors have had long experience bringing considerations of spirituality inmedical care to the attention of the medical profession, as well as all other healthprofessionals This volume is encyclopedic, culturally, and historically It shouldprove to be an authoritative source for years to come It provides the kind ofserious combination of practice and theory essential to our understanding ofwhat ‘healing’ really means to patients and the health professionals whosincerely want to use scientific medicine along with a true wholistic approach tothe care of those they commit themselves to as authentic healers

This is a book about the dimension of life that we refer to as spiritual and itsplace in healthcare The conjunction of the two is historical, intellectual, andpractical, because both intersect around the human concern and critical interest

we have in health Bringing together a volume dedicated to spirituality andhealthcare is therefore never far removed from a dialogue on the meaning andcharacter of health, on the human capacity for sustaining health, and on theingenuity and creativity we have to respond to those things that disrupt ourhealth and cause us to renegotiate what it means to be human Spirituality is formany people a way of engaging with the purpose and meaning of humanexistence and provides a reliable perspective on their lived experience and anorientation to the world As spirituality engages healthcare it becomesinextricably linked with human suffering and therefore integral to the lives ofpatients, their families and their caregivers Inevitably, if healthcare has anyregard for the humanity of those it serves it is faced with spirituality in itsexperienced and expressed forms How is healthcare to engage and respond, howdoes it understand and interpret spirituality, what resources does it makeavailable and how are these organised, and how does spirituality shape andinform the purpose and practice of healthcare? These questions are the basis forthis book and outline a coherent field of enquiry, discussion and debate that isinterdisciplinary, international and vibrant We have aimed to capture thisthrough a collection of writings involving authoritative and leading-edge writers

to provide a unique resource and a stimulating discourse

Anyone who reads healthcare journals, attends healthcare conferences, orreceives course brochures cannot fail to have noticed that spirituality is on theagenda Similarly, an awareness of current affairs is a reminder that religion isback in the public square, if it were ever absent Religions bring people intorelationship with the spiritual dimension and with others seeking the same; theyprovide social structures and identity, and maintain living traditions of practiceand wisdom The innate human capacity for spirituality means that many of

these religious traditions are ancient relative to healthcare and have thereforecontributed to current globalized understandings of health, healthcare, andspirituality The opening section of the book therefore considers key traditionsand explores particular strands of thought, many religious, and their contribution

to these contemporary perspectives Some chapters outline ways in which livingtraditions underlie and continue to support values important to contemporaryviews of health and healthcare Others look at ways in which these values havebeen received, adapted, challenged, or reinterpreted by modern social thought orpost-modern revivals of neglected traditions Notable alongside chapters onreligious traditions are those on the humanist tradition, secularism andphilosophy, all of which expand and challenge conventional notions and aretopics of contemporary relevance

An exploration of spirituality and healthcare is premised upon concepts andconstructs that often go unexamined Terms are used that may not be commonlyunderstood and the language of spirituality and healthcare is replete withvocabulary that is underpinned by assumptions We therefore devote a section ofthe book to significant concepts in this field with the aim of developing clarity inthe discourse By unpacking and critically reflecting on terminology we discovernew insights, helpful differentiations and possible inter-relationships that canfurther the discursive knowledge of this developing field However, spiritualityand healthcare have practice as their primary mode and it is inevitable that thelargest section of the book addresses ways in which the spiritual is addressed inthe practice of healthcare No one discipline has an exclusive claim becausemany are involved in caring relations, although some have a greater historicperspective, social validation, training, and formation Practice has alsodeveloped around the specialist subdivisions of healthcare and this has resulted

in particular approaches described in some of the chapters Significantly,spirituality has been a challenge to healthcare practice particularly in terms of itsattentiveness to the person, its responsibility and responsiveness to the ways wemake sense of life, and its capacity to cultivate the co-creation of health insituations of vulnerability We are therefore faced with questions about whetherand how spirituality should be incorporated into developed disciplinarypractices, whether it should it be a specialist adjunct, and how spirituality mayrelate to the vocational and humanistic intentions of healthcare practitioners.Healthcare is a seedbed of research, substantially in the physical sciencesrelated to the immediacy of problematic human bodies, and to a much lesserextent in the social and behavioural sciences related to the lived experience andsocial environment of being human Research inquiries are driven by questionsabout what disrupts health and how it can be restored and therefore the

relationship between spirituality and health has become an obvious subject ofstudy, although not one as current as people assume Francis Galton's prayerstudy was originally published in 1872 and he asserts that, ‘The efficacy ofprayer seems to me a simple, as it is a perfectly appropriate and legitimate,subject of scientific inquiry Whether prayer is efficacious or not, in any givensense, is a matter of fact …’(1) Contemporary research has an array oftechniques and instruments available to it by which it can scrutinize spirituality

in relation to health, but many results are far from conclusive or uncontested.Research provides intelligible, rigorous and systematic methods to investigateand describe claims about the world that spirituality cannot avoid for ethicalreasons alone However, research in this field is relatively immature, andwhatever the use of explanatory empirical inquiries there is also a need todevelop and be confident in methods of inquiry that help us to better describeand understand the experience and expressions of particular spiritualties and theactual practices of spiritual care

If spirituality in healthcare is to move beyond the ad hoc arrangements and

particular interests of individuals that it commonly relies upon then it mustbecome better integrated within health systems This purposeful approachrequires explicit policy directed at improving spiritual care through theallocation and organisation of resources, the attainment of standards related tothe structures, processes, and outcomes of healthcare, and the development ofconsensus and shared understanding We have examples of this approach withinthe book, but this agenda needs development, and lessons need to be learnt fromhealth systems that have adopted and implemented policy in this field Alongsidepolicy development healthcare practitioners need opportunities to learn aboutspirituality and develop their skills and capacities to attend to the spirituality ofpatients as well as that of their own This means not only developing ways ofattending to suffering with deep compassion and altruism, but also doing so incareful and competent ways Training is therefore critical and requiresintentional programming, appropriate educational methods, such as inter-professional education and collaborative learning, and its incorporation intoprofessional formation Without this healthcare practitioners are likely to beuncertain of their response, anxious of failure, ineffective in practice andunaware of ethical consequences

Spirituality and healthcare share another common characteristic: both havedeep historic roots, but remain highly dynamic and adaptive In the last section

of the book we therefore explore some of the challenges within this field andconsider how some of the dynamic interactions might play out No discussioncan take place without considering the future of religion, which presents a range

of scenarios, and the need to understand the shifting place of religion in society.Similarly, discussions must include secular, humanistic, and culturalperspectives These social contexts are the place of healthcare and therefore theybecome an important backdrop and influence on how spirituality is conceived,located and practiced in healthcare organizations What is evident is that thespiritual within healthcare is far from homogenous and includes conventionalreligious forms, secular spirituality and therapeutic forms of spirituality eachwith their own possibilities and contentions What seems undeniable therefore isthat spirituality has opened up a dialectic space in healthcare, often dominated

by reductionism, that allows people to make some sense of the transcendentaspects of health and humanity The engagement of spirituality with healthcarecan thus be seen as a core strategy for humanizing healthcare through its focus

on inner meaning, approaches to suffering, and compassionate practice It canalso be seen as a core strategy for grounding spirituality in the encounter withhuman finitude

Finally, in presenting a subject with the depth and breadth evident in this bookhas required working with a large group of expert individuals across the worldand this has presented its own rewards and challenges We are indebted to all ourcontributors for their commitment to this book, to our colleagues world-widewhose perspectives have challenged our thinking and broadened our views, and

to our patients and those for whom we care, who are the reason for our passionand commitment to create more compassionate and holistic systems of care Wealso thank Amber Morley Rieke for her administrative assistance and the team atOxford University Press for their perseverance and guidance in making this book

Shane Sinclair and Harvey M Chochinov

41 Pastoral theology in healthcare settings: blessed irritant for holistic human care

Assistant Professor in the McGovern Center for Humanities and Ethics at The

University of Texas Health Science Center at Houston (USA) Harvey M.

Sr Chaplain and Clinical Director at Sheffield Teaching Hospitals NHSFoundation Trust; Honorary Research Fellow, Academic Palliative andSupportive Care Studies Group, University of Liverpool; Honorary Lecturer,

Psychiatry, Harvard Medical School (USA) Fiona Gardner

Senior Lecturer, Social Work and Social Policy, School of Rural Health, La

Senior Research Professor in Sociology of Contemporary Spirituality,

Department of Sociology, Erasmus University Rotterdam (NLD) Margaret

Senior Lecturer, School of Divinity, The University of Edinburgh andProgramme Director for Healthcare Chaplaincy and Spiritual Care, NHS

Alister E McGrath

Professor of Theology, Ministry and Education, and Head of the Centre for

Theology, Religion and Culture at King's College, London (UK) Wilfred

Research Scholar, Kennedy Institute of Ethics and Interim Director, Center for

Human Behavior at University of California, Los Angeles (USA) Mary Pat

Associate Professor, Department of Arts, Communication and Critical Enquiry,

Faculty of Humanities and Social Sciences, La Trobe University (AUS) Carol

Trevor Stammers and Stephen Bullivant 14 SikhismEleanor Nesbitt

Concepts of health reflect the culture in which they develop Health is a conceptthat is imprecise Words that denote health are semantically related in manylanguages to concepts of physical wholeness, and are synonymous with healthand wellbeing They may refer to the body, the mind, or the soul Health andphysical wholeness were thought by the Mesopotamians and Egyptians to bepresent so long as life remained in harmony with the forces of nature Illness

reflected disharmony between the individual and the total environment Shalom, which is often translated as peace, was a Hebrew concept that denoted a broad

and inclusive concept of health that included spiritual well-being This may be

seen in the Hebrew Bible, where health is consistently described in spiritual,rather than in medical terms.[1] In contrast, the Greek medical view of health

(hugieia) was that it represented an equilibrium or harmony of various elements

of the body, such as bodily fluids or matter taken into the body The Greeksviewed disease as a disturbance of that equilibrium Their best-known theory ofphysiology was based on the supposed existence of four humours or bodilyfluids (blood, phlegm, yellow bile, and black bile), borrowed by physicians fromthe pre-Socratic philosopher Empedocles (fl 444–441 BCE) When the balance ofhumours was disturbed or upset, medical treatment consisted of restoring them

to their correct proportions, in harmony with nature, rather than contrary to it.[2]The Greek view of health furnished an analogy for the soul, in which moral

virtue (arête) was considered a balance of the elements of the soul Philosophers

sometimes referred to the soul as sick or diseased A healthy individual guardedagainst diseases of the soul by practicing moderation and self-control

(sophrosune) Hence, medicine and philosophy complemented each other and

enabled one to lead a balanced life whose end was happiness[3] (mens sana in

corpore sano, ‘A sound mind in a sound body’).[4] The body–soul analogy wasused by writers of nearly all Greek philosophical schools The Christian beliefthat pain and suffering had a redemptive or sanctifying purpose was unknown inthe classical world, in which health was so basic to the enjoyment of life that alife without it was not thought to be worth living Health was never regarded byearly Christians as a virtue, as it had been for the Greeks, but a blessing that wasgiven by God The World Health Organization defines health as a ‘state ofcomplete physical, mental, and social well-being, and not merely the absence ofdisease or infirmity’.[5] This is a broad conception that appears to make healthnearly indistinguishable from happiness, and is not far removed from thoseancient views of health which emphasized a wholeness that encompassedphysical, mental, and spiritual health It is also reflected in definitions of healththat one finds in New-Age and ‘holistic’ healing movements associated withcomplementary and alternative medicine, in which well-being is achieved bycreating a balanced personality in which mind, body, and spirit are in harmony

Disease: its causes and cure

The ancient world was animistic or polytheistic with a few exceptions, notablyIsrael, which was monotheistic, and Persia, whose religion, Zoroastrianism, wasdualistic Each locale (village, city) had its own cults and deities, but thesyncretistic nature of polytheism resulted in local deities being merged withothers over time to form national pantheons Their view of the world was

predominantly an organicist or vitalist one; they viewed it as animated by vaguenuminous or spiritual presences, which could be manipulated through a complexvariety of magico-religious mechanisms that could be employed to maintain orrestore health The earliest historical (that is, literate) civilizations of the NearEast arose in Egypt and Mesopotamia at the beginning of the third millennium

BCE Egyptians and Mesopotamians viewed any but the most common diseasesaetiologically, rather than symptomatically Disease could be inflicted by bothpernicious supernatural powers and humans who had access to the use ofmalicious magic Disturbances to one's health could be understood only bydiscerning the identity and motives of the responsible agent Medical craftsmen

(the asu in Mesopotamia, the swnw in Egypt), who mingled empirical methods

in treating acute symptoms with prayers and incantations, were consulted.Magical healing employed amulets, incantations, or occult objects like herbs andgems, which manipulated hidden preternatural forces that were within nature,but outside its normal course While folk medicine, a component that is found inevery culture, including our own, and empirical treatments were used, treatmentreflected a magico-religious classification of disease in which the aims ofmedicine were subordinated to those of religion Since everything that was notreadily explicable was believed to have happened for a purpose, sickness hadmeaning that could be ascertained by its interpreters Breaking a taboo couldoccasion divine anger and bring about disease, but the gods sometimes struckcapriciously The Babylonians attributed some disease to demons, as did theEgyptians and their neighbours Common physical ills that aroused no awe wereviewed symptomatically, and treated with herbs or other natural substances.[6]

In the fifth century BCE Greek medicine began to take on the form of a science

as well as a craft A science requires the existence of a body of theoreticalknowledge, which until the late fifth century did not exist in medicine Manyempirical techniques had been collected and transmitted by empirics or folkhealers, but they could not be called a body of knowledge There had been noprevious attempt to understand disease in general terms or to frame broadtheories that could be applied to particular cases It was the addition of theory tomedicine and concepts of disease that made it possible to explain disease interms of natural causation, which became a feature of Greek medicine in the fifthcentury Physicians who sought a theoretical understanding of disease turned tophilosophy, which alone could provide universal formulations We term these

physicians (iatroi) Hippocratic physicians after the celebrated father of

medicine, Hippocrates

Although Hippocrates was the subject of much legend, we know almostnothing about him Only two contemporary references to him exist, both in the

dialogues of Plato He probably became the subject of widespread interest duringHellenistic times, when a number of anonymous medical works came to beattributed to him They are known as the Hippocratic Corpus and they numberabout 60 treatises None of them can be attributed to Hippocrates with anycertainty They are a disparate group of medical writings, most of them probablyhaving been composed in the fifth and fourth centuries BCE, but some as late asthe second century BCE They reflect a variety of points of view ManyHippocratic treatises reveal an approach to medicine that is both rational andempirical: rational in its freedom from magic and demons, and in its belief in thenatural causes of disease; and empirical in the collection of case histories withcareful descriptions of symptoms.[7]

Side by side with the development of a naturalistic tradition of medicine inclassical Greece, there existed a parallel tradition of religious medicine in whichthe sick sought healing directly from a god, rather than a physician Those whodesired divine help for healing could appeal to a wide variety of gods, demigods,and heroes Originally, there were no special gods of healing Any deity could beinvoked by the sick But one hero, Asclepius, came to be the chief healing god ofthe classical world By the fourth century BCE the northern Peloponnesian city ofEpidaurus became the centre of a healing sanctuary of Asclepius and from therehis cult spread throughout the Greek and Roman world The sick came to histemples seeking supernatural healing, often for diseases that physicians couldnot cure Pilgrims first underwent a rite of purification and offered a smallsacrifice The actual healing process involved incubation, the practice of having

pilgrims spend the night in the abaton, where they were to lie on a couch and

wait for a dream or a vision of the god, in which Asclepius would appear to heal

or advise them The god often appeared holding a staff with a snake coiledaround it (the caduceus), which became associated with him Sometimes hemerely touched patients, sometimes he operated on them or administered drugs,and sometimes a sacred serpent or dog would lick the wounds When patientsawoke the next morning they might find themselves cured Those who werehealed left votive offerings, which have been found in abundance and testify toactual cures They include terracotta models of eyes, ears, limbs, and otherorgans that had been healed

However, Asclepius also healed through physicians by natural means just as

he did by miraculous means through incubation He became the patron ofphysicians who practiced secular medicine, as well as of their patients.Physicians swore oaths by Asclepius and other healing gods They had noobjections to religious healing; rather they viewed it as complementing their ownwork When Greek physicians believed they could not help a patient they

refused to provide treatment The patient might then seek the direct help ofAsclepius The two traditions existed side by side, often with little contact, butwith no apparent tension During the Hellenistic period (323–30 BCE) thatfollowed the death of Alexander the Great a number of foreign deities enteredGreece from Egypt, Syria, and Asia Minor While several of them (such asSerapis) inspired healing cults, none seriously challenged the primacy ofAsclepius.[8,9]

Medical ethics

The best known of the Hippocratic collection is the so-called Hippocratic Oath

It is uncertain when it was written, although the earliest mention of it was in thefirst century CE There is no evidence that it was used in the pre-Christian era.Those who took the Oath swore by Apollo, Asclepius, and other gods andgoddesses of healing to guard their life and art ‘in purity and holiness.’ Some ofits injunctions (e.g prohibition of abortion, euthanasia, and perhaps surgery),together with its religious tenor, suggest that it originated among a limited group

of physicians The oath was regarded by some pagan medical writers during theRoman imperial period as setting forth an ideal standard of professionalbehaviour, but at no time was it used in the classical world to regulate thepractice of more than a minority of physicians.[9]

The deontological treatises of the Hippocratic Corpus (e.g Precepts,

Decorum, Law) provide the earliest writings that deal with medical etiquette.

They define a distinct identity for the physician and establish guidelines forprofessional conduct They are rooted in the culture of the medical craftsman,rather than in any religious or moral values In defining the obligations of thephysician, they both created a tradition of medical ethics and formulated an ideal

of competent practice, which were subsequently adopted in late Romanantiquity, and in the Middle Ages by Christian, Jewish, and Muslim physicians.They have influenced the Western medical tradition up to the present day andremain one of the greatest legacies of Hippocratic medicine.[10]

In the medical-ethical literature of the early Middle Ages, the religious andphilanthropic ideas of monastic medicine were merged with the earlier seculartradition of Hippocratic medical ethics Both came to form important strands inWestern medical ethics With the introduction of the Christian emphasis oncompassion as an essential motive of the physician, one can speak of somethingnew in medical ethics—an element that cannot be said to have been represented

as an ideal in pre-Christian medicine.[11]

Beginning in the Middle Ages moral theologians in the Western (later Roman

Catholic) church created and modified over time a highly intricate system ofethics based on canon law In the area of medical ethics it historically focused onissues at the beginning and end of life, such as contraception, abortion, andeuthanasia Since the Council of Trent (1545–1563) there has been a strongemphasis placed on the natural-law tradition, which views God's purposes asevident in the nature of every human act The concept of natural law, whichowes much to Aristotle, has been basic to Roman Catholic medical ethics It iscapable of great subtlety and has produced much ingenuity in defining itsapplication to medical ethics For example, the Catholic position historicallystressed an intrinsic connection between the unitive and procreative purposes ofsexual expression in marriage Because it regarded the natural intent of sexualintercourse to be to conceive children, the prevention of conception by artificialcontraception was believed to be unnatural and therefore sinful.[12]

Protestantism differed from both the Roman Catholic and Orthodox churches

in resting the church's authority on Scripture alone (sola scriptura) The Bible

has been the touchstone by which all matters of theology, morals, andecclesiastical practice were to be tested Protestantism has tended to reject theformulation of a detailed system of ethics and to roll ethics back into systematictheology Protestant medical ethics arose more directly from religiousconsiderations of health and disease, as well as from biblical themes likeprovidence, justification, law and grace, covenant, and the place of suffering inthe Christian experience Hence, Protestantism never produced a tradition ofcasuistry similar to that of Roman Catholic canonists Instead, Protestantsstressed ‘commandment and conscience’ (or ‘norm and context’) as the twinpillars on which ethics should be based: the application of general biblicalprinciples to particular situations The individual alone before God was a basicProtestant theme The cultivation of the private conscience, which sought toapply the text of Scripture to concrete ethical situations, became its characteristicemphasis On a number of questions in medical ethics that did not admit of easysolution because the biblical evidence was not clear, Protestants took divergentapproaches Thus, against the traditional Roman Catholic position that suicidewas a violation of the sixth commandment and a sin that precluded repentance,

some Protestants (like John Donne in his famous essay Biothanatos [1607–

1608]) argued that God might forgive suicides and that one could not judge thestate of the mind or heart that led them to take their own lives In the last third ofthe twentieth century liberal and conservative Protestants became deeply divided

in their attitudes to a variety of issues in medical ethics, particularly abortion andeuthanasia The divide reflected their disagreement over whether biblicalprohibitions were merely culturally conditioned, or absolute and binding on

modern societies On ethical issues raised by new medical technologies, such ascloning and stem-cell research, consensus among Protestants has been lacking,given the insistence within the tradition on the exercise of private conscience.One issue that both have agreed upon is opposition to genetic engineering.[13]

Theodicy

In every culture societies have attempted to account for suffering in general and

sickness in particular We term these attempts theodicies In the ancient world

the most common explanation for suffering was that misfortune was retributive.When the gods were angry they sent plague, drought, famine, flood, defeat inbattle, or some other calamity, which could only be removed by sacrifice or

purificatory rites that would propitiate the gods or spirits (numina) by appeasing their anger Homer's Iliad (Bk 1, lines 43 ff.) provides a well-known example.

The epic begins by describing a plague that has afflicted the Greek forcesbesieging Troy The Greeks attribute the calamity to Apollo, who has for beenaiming pestilence-carrying arrows at his victims for 9 days, with the result thatpiles of corpses were being burnt On the 10th day a seer is consulted todetermine why the god is angry Once he discovers the cause, Apollo ispropitiated and the plague ends Throughout antiquity devastating naturaldisasters, such as plague, stimulated not only popular religious fervour, but alsothe tendency to look for scapegoats Thus natural disasters evoked persecution ofearly Christians on the ground that toleration of these ‘atheists’ had provoked thewrath of the gods

The tendency to moralize sickness by rendering its victims as sinners in need

of repentance was a late development in Egyptian and Mesopotamian religion,but it came to be widely held in antiquity that the sick were suffering deservedlybecause their disease was retributive A sick person was not viewedcompassionately, but as the recipient of deserved punishment One finds thisattitude everywhere in the Ancient Near East, including the Hebrew Bible Onedoes not pity the sick, but encourages the person to repent This is the attitude ofBildad the Shuhite, one of Job's comforters, who warns Job that Yahweh actsjustly Job and his sons have sinned against him, but if he repents and remainsupright in his behaviour, Yahweh will prosper him (Job 8:1–10) Bildad's attitudetranscends cultural boundaries and one finds it everywhere in the ancient world.[14] So deeply rooted was this cultural prejudice that it hindered theestablishment of any charitable concern for the sick

Early Christians formulated a view of the human condition in which sufferingassumed a positive role that it had previously lacked They believed that, rather

than bringing shame and disapproval, disease and sickness gave to the sufferer afavoured status that invited sympathy and compassionate care.[15] In theclassical world neither philosophy nor religion encouraged a compassionateresponse to human suffering During times of plague, the sick and dying wereabandoned, and corpses often left unburied in order to prevent the spread ofcontagion This may be seen in a contemporary account by Dionysius, Patriarch

of Alexandria, of the Plague of Cyprian in the mid-third century

The heathen behaved in the very opposite way At the first onset of the disease, they pushed the sufferers away and fled from their dearest, throwing them into the roads before they were dead, and treating unburied corpses as dirt, hoping thereby to avert the spread and contagion of the fatal disease; but do what they might, they found it difficult to escape.[ 16 ]

This description can be paralleled by several passages that describe popularreaction to plague in the classical world Christians viewed suffering as anopportunity to provide care of the sick and dying, while at the same time theysaw in it an opportunity for personal self-examination that could bring spiritualillumination While Christians believed that suffering might be God'schastisement for sin, they did not posit a simple correlation between sin andsuffering Rather they viewed it as a means of grace for the spiritual benefit ofthe sufferer So universal, however, has been the connection between moralfailing and sickness that it has remained a dominant theodicy in many societies,including our own.[17]

Beneficence

Classical society saw in philanthropy (philanthropia, ‘love of humanity’) a

potential motive for the practice of medicine, but it was never believed to be anessential virtue The Greek physician Galen (CE 129–ca 210 or later), indiscussing the several motives that might cause individuals to engage in themedical art, listed a variety of possible incentives They included philanthropy,

as well as a desire for money, honour, and immunities from taxation However,

he thought that only competence was essential Greek and Roman philanthropyexcluded pity as a motive for medical treatment and thereby differed markedlyfrom Christian concepts of medical charity in both motive and practice Thelarger cultural values of Graeco-Roman society also militated against medical

philanthropy They included the Stoic conception of apatheia (insensibility to

suffering) and a spirit of quietism that thought it impossible to improve theworld We can assume that many pagan physicians, in fact, demonstratedcompassion towards those whom they treated Nevertheless, in the classicalworld there existed no virtue or ideal of compassion that was urged uponphysicians One finds a few, such as Scribonius Largus, a first-century medical

writer, who believed that it is essential, but in general the virtuous physician wasnot expected to display philanthropy in his medical practice Christianityintroduced a very different set of values from those that dominated the classicalworld, which over time came to underpin the ethics of medical practice.[18]Basic to Christianity was a philanthropic imperative that sought to meetphysical needs Whereas Graeco-Roman values included no religious impulsefor charity that involved personal concern for those who required help,

Christianity based its charity on agape, which reflected the incarnational and

redemptive love that God had displayed in Jesus Christ, who by his death on thecross provided a model for the sacrificial love of one's fellow human beings OfJesus’ teachings none was more influential in this regard than the parable of theGood Samaritan (Lk 10:25–37), which served as an encouragement to care forthe sick The imperative of the parable became a motivating ideal of theChristian physician: ‘Go and do likewise’ (v 37) Compassion, hitherto unknown

in Greek medical ethics, became an inspiration for the care of the sick.[19]While ordinary Christians were enjoined to visit the sick and aid the poor, theearly church established congregational forms of organized assistance Each

congregation (ecclesia) maintained a clergy of presbyters (priests) and deacons,

who cooperated in the direction of the church's ministry of mercy The relief ofphysical want and suffering was assigned to deacons, who regularly visited thosewho were sick, while presbyters had charge of the administration of funds to aidthem Once each week alms were collected and distributed among the sick andthe poor Widows formed a special group to visit women and the office ofdeaconess grew out of the practice Early Christian medical charity wasdeveloped while the churches were small, scattered, and experiencingpersecution by the Roman government Yet it was both effectively organized andextensively practiced In the first two centuries of its existence, the Christianchurch created the only organization in the Roman world that systematicallycared for its sick.[20]

There were no pre-Christian institutions in the ancient world that served thepurpose that hospitals were created to serve, namely, the offering of charitableaid, particularly health care, to those in need Roman infirmaries, called

valetudinaria, were maintained by Roman legions and large slaveholders, but

they provided medical care to a restricted population (soldiers and slaves), and

were not charitable foundations The earliest hospitals (nosokomeia, xenodochia)

grew out of the long tradition of the care of the sick in Christian churches Thebest known, and the earliest, was the Basileias, begun about 369 and completed

by about 372 by Basil the Great, who became bishop of Caesarea in Cappadocia(Turkey) His hospital employed regular live-in medical staff who provided not

only aid to the sick, but also medical care in the tradition of secular medicine Itincluded a separate section for each of six groups: the poor, the homeless andstrangers, orphans and foundlings, lepers, the aged and infirm, and the sick.Hospitals spread rapidly in the Eastern Roman Empire in the fourth and fifthcenturies, with bishops taking the initiative in founding them They appeared inthe Western Empire a generation after they were established in the East, but theirgrowth was much slower in the West owing to economic difficulties Hospitalsand other charitable medical institutions were recognized as peculiarly Christianinstitutions Only a minority of them had the resources to employ physicians,and they existed in the Byzantine East In Western Europe there were fewphysicians in hospitals until the end of the Middle Ages Early hospitals andrelated institutions grew out of the monastic movement, and the widespreadexistence of monastic orders provided much of the personnel to staff them.Hospitals were founded specifically to provide care for the poor (Basil called his

hospital a ptōchotropheion or poorhouse) The pattern persisted until the

mid-nineteenth century, and hospitals remained for centuries what they had beenintended to be from the beginning, institutions for the indigent Those who couldafford a physician's care received it in their homes.[21] The large number offaith-based hospitals that were founded in North America indicates howseriously religious traditions took their call to medical philanthropy

In the sixth and seventh centuries lay charitable orders came to be attached tolarge churches in the major cities of the Byzantine Empire The best known were

the philoponoi (‘lovers of labour’) and spoudaioi (‘the serious ones’) They were

largely drawn from the lowest class and had no medical training, but they soughtout the homeless who could be found everywhere in the large cities of theeastern Mediterranean, bathed and anointed them, and provided them withpalliative care.[22] Many similar movements have existed in the history ofChristian philanthropy Roman Catholics have excelled in organizing andinstitutionalizing their medical charities, including hospitals, most of themmaintained by religious orders of women The Sisters of Charity, founded by StVincent de Paul (1580–1660), became a major force in caring for the sick.[23] ALutheran order, the deaconess movement, was founded in the nineteenth century

by two German pastors, Theodore Fliedner and Wilhelm Loehe, who wereinfluenced by a Mennonite deaconess movement in Holland, and by the EnglishQuaker Elizabeth Fry It began at Kaiserswerth and soon spread throughoutEurope Florence Nightingale took her training at Kaiserswerth before opening aschool of nursing in England.[24] Medical missions constituted another branch

of Christian medical philanthropy Missionaries to European colonialpossessions often established medical facilities and much of their work was

invested in the founding of hospitals, leprosaria, and other health-relatedinstitutions.[25] Medical philanthropy has spread to many other faith traditions,most particularly, Jewish and Muslim.

Religious healing

The New Testament Epistles indicate that early Christians experienced ordinaryillnesses, of which they were sometimes healed and sometimes not Biblicalwriters do not condemn secular medicine; in fact, although the evidence is slight,

it appears that early Christians routinely employed it, as did most other religiousand non-religious populations within the Mediterranean world.[26] Belief inreligious healing has, however, always existed in Christianity, less frequently inthe mainstream and more often on the sectarian fringe Origin (ca 185–ca 254)maintained that Christians who wished to live in an ordinary way should usemedical means, while those who wished to live in a superior (i.e more spiritual)

way should seek prayer for healing (contra Celsum 8.60) While there is little

evidence that religious healing was prominent in the first three centuries, by thefifth century it had emerged as an element in Christian practice Claims ofmiraculous healing were ubiquitous in the Middle Ages, especially focused onthe tombs and relics of saints, which were believed to possess miraculoushealing properties Miracles became part of ordinary life, most of them claimedfor the healing of a physical affliction Pilgrimages to these shrines becameenormously popular.[27] The Roman Catholic and Orthodox churches havecontinued to claim that miraculous healing occurs in the modern world as ademonstration of God's working in his church Protestants by contrast havehistorically held that miracles ceased after apostolic or early Christian times.While they believed that God healed in answer to prayer, they consideredmiraculous healing (i.e healing apart from medical means) to be rare In themid-nineteenth century, however, faith healing gained credence in some circles

of American Protestantism, largely through Methodist influences, although mostmainstream Protestant traditions rejected it.[28]

At the turn of the twentieth century a new movement, Pentecostalism, claimedthat supernatural gifts of the Holy Spirit, such as glossolalia (i.e speaking inunknown languages) and supernatural healing, were normative for the church inevery age The movement began in 1901 with Charles Fox Parham, a faithhealer His teachings were carried to Los Angeles, where they led to the AzusaStreet revival, widely regarded as the beginning of Pentecostalism in America.Pentecostalism grew rapidly in the first two decades of the twentieth century Ittaught that Jesus’ death on the cross atoned not only for sin, but for disease as

well Hence, Christians could claim supernatural healing as a result of the

‘prayer of faith.’ Pentecostalism produced many itinerant healers who claimed topossess the gift of miraculous healing, with some practicing exorcism, regardingdemons as a cause of illness A minority of Pentecostals recognized medicine as

an alternative to supernatural healing, albeit an inferior one Many rejectedmedicine as unfaithful to God's unconditional promise to heal In the latter half

of the twentieth century some Pentecostals modified their categorical rejection ofmedicine Since the 1950s, Pentecostal influences, often without their sectariantrappings, influenced mainstream Protestant and even Roman Catholic churches.The ‘charismatic renewal,’ as it came to be called, gained widespread influence

as it introduced healing, sometimes in a sacramental fashion, to churches thathad not traditionally practiced it, particularly in liturgical traditions, such asAnglican and Lutheran.[29]

Much popular Roman Catholic piety remained outside the control of theinstitutional structure of the Church While educated Catholics might considersome manifestations of Catholic piety, especially those that syncretized pagansurvivals, as superstitious, they reflected an important aspect of Catholic piety.There existed within the Church a tendency, which was not limited to post-tridentine Catholicism, to blur the distinction between ecclesiastically-sanctioned (usually sacramental) rites and folk practices The approvedobservance of venerating relics and blessing animals, for example, has seemed tosome Catholics not very different from popular cults that attributed healing tostatues of the Virgin Mary Hence, there remained a place for religious healingwithin the larger confines of the Church, such as that which existed withinPentecostalism Chief among them was the miraculous healing offered atpilgrimage sites Beginning in the nineteenth century, Lourdes in France, Fatima

in Portugal, and Guadalupe in Mexico drew huge numbers of pilgrims year afteryear, in spite of the revolutionary advances of medicine that were taking place.[30]

Secularization and alternative healing

In the late nineteenth and early twentieth centuries Western societies underwentrapid secularization in nearly every public sphere The professionalization ofmedicine eliminated from medical practice those without formal training inmedicine, including clergymen who had practiced medicine, particularly in areasthat were without physicians A new emphasis on training in the sciencesresulted in raising standards considerably for students entering medical schools

As medicine became a secular profession, it moved away from a religious

emphasis on vocational calling and compassionate care The new model ofscience became a naturalistic evolutionary one in which spiritual values werediminished as traditional religion found itself pushed to the margins of society inthe academy and the professions By the mid-twentieth century medicine nolonger had formal ties to religious values No appeal was made to spiritualvalues in medical treatment except in cases where health-care providersthemselves felt a vocational calling Hospitals and charitable medical facilitiesbecame secularized as well, with the decline of religious medical orders and thetransition of faith-based hospitals to community-based or for-profit corporations.Mainstream medical ethicists in the last three decades of the twentieth centuryadopted utilitarian or consequentialist perspectives in place of implicitlyreligious ones.[31]

Concurrent with the growth of secularism has been the widespread followingaccorded New Age spirituality that developed in the latter half of the twentiethcentury.[32] The movement drew on Eastern pantheistic religions andmetaphysical traditions, as well as naturopathy, spiritism, anthroposophy, andtheosophy, which appealed to the newly-fashionable motifs of religiousinclusivism and pluralism It claimed to merge science (which often appeared tooutsiders to be pseudoscience) with an alternative spirituality and sought tocreate an approach to healing that was both holistic and vitalistic (the view thatthe body is animated by a life force).[33] New-Age spirituality became popular

in the 1970s and continues to attract widespread support, even if in a diffusedand attenuated fashion Indeed, it might be considered a component of the spirit

of the age Because it rejects defined theology and creedal formulations infavour of more pantheistic views, it has coalesced easily with modernsecularism, and has influenced education and the professions, includingmedicine Complementary and alternative medicine (CAM) is very much acomponent of New-Age belief, which rejects ‘biomedical ethnocentrism’ andallopathic medicine in favour of self-healing and self-realization (the two areoften intertwined) that are intended to create a harmony of body, mind, andspirit They include elements of traditional Chinese medicine (TCM), such asT'ai Chi, acupuncture, and herbal remedies, as well naturopathy and variousforms of psychic healing While some of these practices remain marginal, others(such as yoga and acupuncture) have been incorporated into routine medicalpractice There is a strong spiritual component in much of CAM, sometimesderived from Hindu or Tibetan roots, sometimes from Native American orEuropean pagan backgrounds However, it more commonly appears as anamorphous patchwork of folk-healing practices drawn from a wide variety of

‘spiritual’ sources, rather than traditional religious communities, and is little

noticed because it operates outside conventional medicine In this sense, itresembles nineteenth-century American religions that had an alternative medicalcomponent, such as Seventh Day Adventism and Christian Science.

Consolation

In the intersection of religion and medicine, religion has played no greater rolethan that of providing consolation in sickness and death It is an ancienttradition When Job had been afflicted with the destruction of his family andpossessions, and was covered with boils, three of his friends came to consolehim For 7 days they sat with him in silence in a traditional attitude of mourningbefore they spoke (Job 2:11–13) Consolation enjoyed a role, as well in Greekphilosophy Consolatory essays in the form of letters to bereaved friends were agenre that dated back to the fifth century BC. Two of the best known were written

by the Stoic philosopher Seneca (4 BCE–CE 65) on the death of family members

(De consolatione ad Polybium, ad Marciam) The tone of these philosophical

essays is (in the Stoic manner) emotionally detached, however, and they displaylittle sympathy for the personal loss of the recipients More focused on spiritualcomfort was the consolatory literature of a long Christian tradition, which tried

to bring solace to bereaved family members by urging that they seek their help inChrist and employ spiritual remedies to assuage their loss A strong traditionalbelief in providence gave many religious believers a confidence that Godcontrols every aspect of life and death, and that nothing happens by chance Thedecline in a belief in providence in the twentieth century has weakened thiscertainty, which consoled generations of religious believers

For Christians, suffering had a positive role that it lacked in classicalpaganism For the Greek philosopher, physical suffering had no redeeming

qualities In Stoicism, sickness was one of those indifferent matters (adiaphora)

that must be endured Stoics urged impassibility in the face of the death of eventhe closest family members By contrast, in the Hebrew Bible, Jews whosuffered sought consolation from Yahweh, a theme that one sees often in thePsalms (Psalms 27, 46, 121,138; cf Is 61:1–3) Christianity went further,focusing on suffering as an element that God used in the process ofsanctification When suffering was accepted as sent from God, it possessed greatspiritual value Sickness invited self-reflection and, if it was the result of sin, thepossibility of confession, repentance, and restoration of fellowship with God.Painful and chronic disease brought not self-pity, but the opportunity for drawingcloser to God Job could say at the end of his trials, ‘I had heard of you by thehearing of the ear, but now my eye sees you’ (Job 42:5)

a ministry of pastoral care of the sick Consoling those who suffer has been one

of the most important duties of pastors and priests who were charged with thecure of souls A concern for pastoral care caused some mediaeval monks andsecular priests to study medicine in order to combine medical care with spiritualsolace Similarly, when many towns had no physicians, some Protestant pastors,

as educated men who could understand medical books, acquired knowledge ofmedicine in order to treat the sick in their communities Cotton Mather (1663–1728) of Boston was one such minister He became the focus of controversywhen, during an epidemic of smallpox in 1721, he supported the physicianZabdiel Boylston in advocating inoculation Conservative physicians and thelocal press opposed the practice, but several members of the local clergy

supported Mather Mather called the care of the soul and the body the ‘angelical conjunction.’ In his Magnalia Christi Americana (1702) he devoted a major

section to biographies of New England's founders, many of which detail theirsuffering as contributing to their Christian character.[34]

‘In the midst of life we are in death.’[35] The care of the dying was anextension of the ministry of consoling the sick In the fifteenth century a genre ofliterature grew up that was intended to prepare one for a Christian death

Treatises on the ‘art of dying’ (ars moriendi) became popular in Europe during

the Black Death A later example of this genre, and the best known in English, is

Jeremy Taylor's classic devotional work, The Rules and Exercises of Holy Dying

(1651) Taylor's treatment of his subject differs from the mediaeval approach byhis making the whole of life a preparation for dying John Wesley, who admiredthe work, made it a practice in his itinerant preaching of visiting jails to offerspiritual counsel to men facing the gallows It was not only compassion for theirlot that pastors offered, but concern for the souls of those about to die Were theyready to meet their Maker? If they were, the pain of this world and the death thatawaited them had its sting removed by anticipation of heaven, which wouldbring release from their suffering, the hope of meeting their loved ones, and thecertainty of seeing their Maker face to face Of the benefits that religiouscertainty offered the dying, none was greater than the hope it gave of the life tocome

Bibliography

On the relationship of medicine and religion

Sullivan, L.E (ed.) (1989) Healing and Restoring: Health and Medicine in the World's Religious Traditions New York: Macmillan.

For a comprehensive treatment of medical ethics in the world's leading faith traditions

12 For the Catholic tradition in medical ethics see Amundsen, D.W (2008) The discourses of Roman

Catholic medical ethics In: R.B Baker, L.B McCullough (eds) The Cambridge World History of

Medical Ethics, pp.218–84 Cambridge: Cambridge University Press.

13 For the Protestant tradition see Ferngren, G.B (2008) The discourses of Protestant medical ethics In: Baker and McCullough [12], pp 255–63.

Quoted in The Nation, 292 (7): Feb 14, 2011, p 30.

18 Galen, On the Doctrines of Hippocrates and Plato (De placitis) IX 5.4 [2] 87–95.

19 [2] 108–12.

20 [2] 113–14.